This pilot study assessed the safety and preliminary data on the efficacy of endoscopic ethmoidectomy in children with chronic sinusitis. A total of 168 patients were evaluated for chronic sinusitis, and 31 were deemed appropriate candidates for ethmoidectomy. All patients were medical management failures. Twenty-six percent of the patients had asthma, 23% had some immune deficiency, 23% had allergies, and 2 patients (1%) had cystic fibrosis. All patients were followed for at least 1 year postoperatively. The only surgical complication was minor middle meatal scarring that developed in two patients. Overall, 71% of the patients were considered normal by their parents 1 year postoperatively. Of the 24 patients who did not have an underlying systemic disease (immune deficiency or cystic fibrosis) postoperatively, 80% were considered normal by their parents, 12% were improved but continued to have some symptoms, and 8% had unsatisfactory results. Seven children with underlying systemic disease had to undergo revision ethmoidectomy for persistent symptoms.

Chronic rhinosinusitis (CRS) is characterized by mucosal inflammation affecting both the nasal cavity and paranasal sinuses; its causes are potentially numerous, disparate, and frequently overlapping. The more common conditions that are associated with CRS are perennial allergic and nonallergic rhinitis, nasal polyps, and anatomical mechanical obstruction (septum/turbinate issues). Other less common etiologies include inflammation (eg, from superantigens), fungal sinusitis or bacterial sinusitis with or without associated biofilm formation, gastroesophageal reflux, smoke and other environmental exposures, immune deficiencies, genetics, and aspirin-exacerbated respiratory disease. A diagnosis of CRS is strongly suggested by a history of symptoms (eg, congestion and/or fullness; nasal obstruction, blockage, discharge, and/or purulence; discolored postnasal discharge; hyposmia/anosmia; facial pain and/or pressure) and their duration for > 3 months. A definitive diagnosis requires physical evidence of mucosal swelling or discharge appreciated during physical examination coupled with CT imaging if inflammation does not involve the middle meatus or ethmoid bulla. Multivariant causation makes the diagnosis of CRS and selection of treatment complex. Furthermore, various types of health care providers including ear, nose, and throat (ENT) specialists, allergists, primary care physicians, and pulmonologists treat CRS, and each is likely to have a different approach. A structured approach to the diagnosis and management of CRS can help streamline and standardize care no matter where patients present for evaluation and treatment. A 2008 Working Group on CRS in Adults, supported by the American Academy of Otolaryngic Allergy (AAOA), developed a series of algorithms for the differential diagnosis and treatment of CRS in adults, based on the evolving understanding of CRS as an inflammatory disease. The algorithms presented in this paper address an approach for all CRS patients as well as approaches for those with nasal polyps, edema observed on nasal endoscopy, purulence observed on nasal endoscopy, an abnormal history and physical examination, and an abnormal history and normal physical examination.

These results will aid physicians when discussing with parents the risks of FES surgery.

Three different vasoconstricting agents were evaluated during functional endoscopic sinus surgery (FESS) in 57 children. Oxymetazoline hydrochloride 0.05%, phenylephrine hydrochloride 0.25%, or cocaine 4% was applied to the nasal mucosa in a prospective, randomized, double-blind fashion. Heart rate and blood pressure changes were recorded 5 and 10 minutes after application of the study vasoconstrictor to each nostril. The surgeon's subjective impressions of bleeding and visualization were recorded for each side of the nose, as were total blood loss and anesthesia time. Although all three vasoconstrictors were tolerated well by the children, there was a suggestion that heart rate decreased more at 5 minutes with phenylephrine than with oxymetazoline or cocaine (P = .08) and that blood pressure increased more at 10 minutes with phenylephrine than with oxymetazoline or cocaine (P = .1). No arrhythmias were noted. Subjective scoring for bleeding showed that children receiving oxymetazoline were less likely to receive scores of "more" bleeding than usual (3/38 vs. 10/34 for phenylephrine and 10/35 for cocaine, P less than .02). Subjective scoring for visualization showed that children receiving oxymetazoline were also less likely to receive scores of "worse" visualization than usual (3/38 vs. 12/38 for phenylephrine and 9/35 for cocaine, P less than .01). There was no difference in surgical bleeding or visualization between children receiving phenylephrine and children receiving cocaine. In our institution, 0.05% oxymetazoline is the preferred vasoconstrictor for FESS in children.

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